Kathleen Papa v. DHS

2020 WI 66
Wisconsin Supreme Court·Decided July 9, 2020·No. 2017AP000634·Published·Cited by 16 cases

Opinion

2020 WI 66

SUPREME COURT OF WISCONSIN CASE NO.: 2016AP2082 & 2017AP634

COMPLETE TITLE: Kathleen Papa and Professional Homecare Providers, Inc.,

Plaintiffs-Respondents-Petitioners, v.

Wisconsin Department of Health Services, Defendant-Appellant.

REVIEW OF DECISION OF THE COURT OF APPEALS Reported at 388 Wis. 2d 474,934 N.W.2d 568 (2019 – unpublished)

OPINION FILED: July 9, 2020 SUBMITTED ON BRIEFS: ORAL ARGUMENT: March 18, 2020

SOURCE OF APPEAL:

COURT: Circuit COUNTY: Waukesha JUDGE: Kathryn W. Foster

JUSTICES: ZIEGLER, J., delivered the majority opinion of the Court, in which ROGGENSACK, C.J., and ANN WALSH BRADLEY and DALLET, JJ., joined, and in which REBECCA GRASSL BRADLEY and KELLY, JJ., joined except for ¶¶46-48; KELLY, J., filed an opinion concurring in part and dissenting in part, in which REBECCA GRASSL BRADLEY, J., joined. NOT PARTICIPATING: HAGEDORN, J. did not participate.

ATTORNEYS:

For the plaintiffs-respondents-petitioners, there were briefs filed by Diane M. Welsh, Aaron G. Dumas, and Pines Bach LLP, Madison. There was an oral argument by Diane M. Welsh.

For the defendant-appellant, there was a brief filed by Steven C. Kilpatrick, assistant attorney general; with whom on the brief was Joshua L. Kaul, attorney general. There was an oral argument by Steven C. Kilpatrick.

An amicus curiae brief was filed on behalf of Wisconsin Hospital Association, Inc., Wisconsin Medical Society, Inc, Wisconsin Dental Association, Inc, Pharmacy Society of Wisconsin, Inc., Wisconsin Health Care Association, Inc., Wisconsin Personal Services Association, Inc., and Leading Age Wisconsin, Inc. by Sarah E. Coyne, Matthew Splitek, James Goldschmidt, and Quarles & Brady LLP, Madison.

2020 WI 66

NOTICE

This opinion is subject to further editing and modification. The final version will appear in the bound volume of the official reports.

Nos. 2016AP2082 & 2017AP634 (L.C. No. 2015CV2403)

STATE OF WISCONSIN : IN SUPREME COURT

Kathleen Papa and Professional Homecare Providers, Inc.,

Plaintiffs-Respondents-Petitioners, FILED

v. JUL 9, 2020

Wisconsin Department of Health Services, Sheila T. Reiff Clerk of Supreme Court

Defendant-Appellant.

ZIEGLER, J., delivered the majority opinion of the Court, in which ROGGENSACK, C.J., and ANN WALSH BRADLEY and DALLET, JJ., joined, and in which REBECCA GRASSL BRADLEY and KELLY, JJ., joined except for ¶¶46-48; KELLY, J., filed an opinion concurring in part and dissenting in part, in which REBECCA GRASSL BRADLEY, J., joined.

HAGEDORN, J., did not participate.

REVIEW of a decision of the Court of Appeals. Reversed in part, affirmed in part, and remanded.

¶1 ANNETTE KINGSLAND ZIEGLER, J. This is a review of an unpublished decision of the court of appeals in two consolidated

cases, Papa v. Wisconsin Department of Health Services, Nos. 2016AP2082 & 2017AP634, unpublished slip op. (July 31, 2019),

Nos. 2016AP2082 & 2017AP634

reversing the Waukesha County circuit court's1 orders granting summary judgment, declaratory relief, and injunctive relief in favor of plaintiffs, Kathleen Papa and Professional Homecare Providers, Inc. (hereinafter "PHP"), and granting supplemental relief and costs and attorney fees. The court of appeals reversed and remanded with orders to enter judgment in favor of the defendant, Wisconsin Department of Health Services (hereinafter "DHS").

¶2 This case requires this court to determine the scope of DHS's authority to recoup payments made to Medicaid service providers. PHP challenges DHS's recoupment policy, as it has been enforced against PHP nurses to recover payments made for services they provided to Medicaid patients. PHP argues that, after DHS has already paid nurses for covered and provided Medicaid services, its practice is to then audit nurses' records and seek to recover the payments if DHS finds any documentation shortcomings. According to PHP, DHS does not contest whether the nurse actually

provided a Medicaid patient with the covered service for which the nurse was paid. Nor does it claim that the payment was

inappropriate or inaccurate. Rather, it recoups payments nurses earned and received for their work because, after the fact, it claims the nurse's supporting records are not perfect. The issue in this case is whether DHS has the authority to enforce this recoupment policy. The short answer is no, it does not.

1 The Honorable Kathryn W. Foster presided.

Nos. 2016AP2082 & 2017AP634

¶3 We conclude that PHP's challenge to DHS's recoupment policy is ripe for judicial determination. We conclude that, under Wis. Stat. § 49.45(3)(f)1.-2. (2017-18),2 DHS may recoup Medicaid payments from service providers only in cases where DHS cannot verify one of the following: (1) the actual provision of covered services; (2) that the reimbursement claim is appropriate for the service provided; and (3) that the reimbursement claim is accurate for the service provided. We further conclude that DHS's recoupment policy exceeds its recoupment authority. Finally, we conclude that the circuit court's order for supplemental relief did not expand the scope of its original order, but that its order for costs and fees was erroneous. Accordingly, we reverse in part, affirm in part, and remand.

I. FACTUAL BACKGROUND

¶4 The Medicaid Program provides free or low-cost health care for low-income people, families, and children, pregnant

women, the elderly, and people with disabilities. "'Medicaid is a cooperative federal-state program through which the Federal

Government provides financial assistance to States so that they may furnish medical care to needy individuals.'" Newcap, Inc. v. DHS, 2018 WI App 40, ¶4, 383 Wis. 2d 515, 916 N.W.2d 173 (quoting Wilder v. Virginia Hosp. Ass'n, 496 U.S. 498, 502 (1990)). "[S]tates voluntarily opt into the federal scheme and thereby bind themselves to abide by the rules and regulations imposed by the

All subsequent references to the Wisconsin Statutes are to 2

the 2017-18 version unless otherwise indicated.

Nos. 2016AP2082 & 2017AP634

federal government in return for federal funding." Gister v. Am. Family Mut. Ins. Co., 2012 WI 86, ¶14, 342 Wis. 2d 496, 818 N.W.2d 880. The States administer Medicaid pursuant to federal requirements set forth in Title XIX of the Social Security Act. 42 U.S.C. §§ 1396-1396w-5. "The State of Wisconsin has joined the federal Medicaid system, and has consequently committed itself to following the federal law governing that system." Gister, 342 Wis. 2d 496, ¶14. DHS administers Wisconsin's medical assistance program. Wis. Stat. § 49.45(1).

¶5 DHS has Medicaid-related responsibilities, including those "relating to fiscal matters, the eligibility for benefits . . . and general supervision of the medical assistance program." Wis. Stat. § 49.45(2)(a)1. DHS is required to "reimburse providers for medically necessary and appropriate health care services . . . when provided to currently eligible medical assistance recipients." Wis. Admin. Code § DHS 107.01(1) (May 2019).3 And, relevant to this case, federal law requires DHS

to audit participating health care providers' records to ensure that all Medicaid payments are proper. See 42 U.S.C.

§ 1396a(a)(42)(A) ("[T]he records of any entity participating in the plan and providing services reimbursable on a cost-related basis will be audited as the Secretary determines to be necessary to insure that proper payments are made under the plan[.]").

All subsequent references to Wis. Admin. Code DHS ch. 107 3

are to the May 2019 register date unless otherwise indicated.

Nos. 2016AP2082 & 2017AP634

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